Final Exam: EM Neurology 211

A 62-year-old male patient with a history of coronary artery disease is being assessed in the ER for an operable intracerebral hemorrhage. He is currently on aspirin and clopidogrel for therapeutic management of his cardiac condition. Prior to performing the procedure, his antiplatelet therapy has to be reversed; hence, desmopressin is the chosen agent for this case.

How does desmopressin function to counteract the effects of antiplatelet medications?

A 19-year-old woman with a history of migraines comes to the ED complaining of a throbbing unilateral headache of an intensity of 8/10. She also exhibits photophobia and has had multiple non-bilious, non-bloody vomiting episodes over the past six hours. She is not currently taking any medications. Among the following, which is the most appropriate treatment for her vomiting?

A 69-year-old female presents to the emergency department with sudden onset of right-sided weakness and difficulty in speaking. An evaluation reveals she is having an acute ischemic stroke. According to the current guidelines from the American Heart Association/American Stroke Association, which of the following are the maximum systolic and diastolic blood pressure values that will still allow for tissue plasminogen activator (tPA) administration?

Mr. DS, a 78-year-old patient with a known history of diabetes, presents to the emergency department one hour after experiencing an Acute Ischemic Stroke (AIS). He was managed on Intravenous alteplase. However, following administration of this treatment, you observe a deterioration in his neurological status. A CT scan subsequently reveals he has suffered an intracranial hemorrhage. In this pressing scenario and given the unavailability of cryoprecipitates, which intervention should you consider next in the management of this patient?

A 50-year-old woman presents to the emergency department exhibiting severe headache, neck stiffness, and photophobia. Her blood pressure is recorded at 155/95 mmHg and pulse at 85 beats per minute. Due to suspicion of subarachnoid hemorrhage, a lumbar puncture is performed. Given the possibility of a traumatic lumbar puncture, which of the following cerebrospinal fluid (CSF) findings is most instrumental for differentiating a subarachnoid hemorrhage (SAH) from a traumatic lumbar puncture (LP)?

A 37-year-old woman with a past medical history of diabetes mellitus, constipation, irritable bowel syndrome, and anxiety disorder, presents to the emergency department with the chief complaint of periodic episodes of intense facial pain that have started suddenly and resolved spontaneously within the past week. She describes the pain as being located on her face, particularly around her eye, severe enough to induce lacrimation. The patient admits to being apprehensive about appearing in public due to fear of an impending episode. On examination, her vitals are temperature 99.5°F (37.5°C), blood pressure 177/108 mmHg, pulse rate 90 beats/minute, respiratory rate 17 breaths/minute, and oxygen saturation 98% on room air. Physical examination reveals pain on palpating the face, while neurological examination shows that cranial nerves II through XII are intact, with both pupils equal in size and reactive to light.

A 36 year-old female with recurrent, severe occipital headaches has been diagnosed with occipital neuralgia. Her physician recommends a treatment approach involving Great Occipital Nerve Blockade (GONB) with corticosteroids using a long-acting local anesthetic. Which long-acting local anesthetic is typically preferred for this procedure?

A 72-year-old female presents to the emergency department (ED) at 10 am with a significant left-sided weakness and aphasia. Her daughter last saw her well when they spoke the previous evening around 6 pm. Examination of the patient confirms severe weakness in the left arm and leg, with notable left homonymous hemianopia and aphasia. Her ECG report shows atrial fibrillation. A CT head scan confirms a large thrombus in the right middle cerebral artery.

Optimally, which of these interventions should the medical team consider first for this patient?

A 77-year-old male with a history of chronic kidney disease and atrial fibrillation, who is not on any regular medications, presents to the emergency department with sudden onset headache, vomiting, and decreased consciousness. He is subsequently diagnosed with a primary intracranial hemorrhage (ICH). The following laboratory data is available: serum creatinine 2.2 mg/dL, INR 2.9. His vital signs are as follows: heart rate 64 per minute, blood pressure 210/118 mmHg, temperature 98F, respiratory rate 16 per minute, and he is mechanically ventilated on 60% FiO2.

In patients with spontaneous ICH, rapid reduction of drastically elevated blood pressure is crucial to prevent further bleeding and to mitigate secondary brain injury. In this context, to minimize the risk of impaired cerebral perfusion, the therapeutic goal is to lower systolic blood pressure to approximately 160 mmHg over a relatively short duration.

Following this guideline, the team administers a specific antihypertensive agent, which successfully brings down the systolic pressure to the desired range swiftly. Which of the following agents is most likely to have been administered, and why?

KH, a 31-year-old male with a history of chronic migraines, presents to the emergency room with a severe migraine, despite taking two doses of sumatriptan (100mg per dose) at home. His nausea hasn’t led to vomiting, and he has no other significant past medical history. His vital signs and lab results are within normal limits. His clinician is considering a sphenopalatine ganglion (SPG) block procedure using topical lidocaine or bupivacaine to manage his persistent headache. Which of the following statements about the SPG block procedure is incorrect?

A 65-year-old man with a past medical history of diabetes and atrial fibrillation arrives at the emergency department showing sudden-onset altered mental state. His wife, who last observed him behaving normally an hour ago, reports his confusion, slurred speech, and muscle weakness after dropping his cup of coffee. The man presents with an inability to answer queries, facial drooping on his left side, and an inability to comply with commands. His temperature is 98.0°F (36.7°C), blood pressure is 150/90 mmHg, pulse is 115/min, and respirations are 17/min. It’s noticeable that he is unable to move his right upper extremity. He is currently on warfarin, however, the specifics of his other medications are unclear. His abrupt onset confusion, asymmetrical smile, and weakness combined with risk factors like atrial fibrillation, diabetes, and hypertension suggest signs of stroke. Beyond further physical examinations, what should be the most suitable next step in management?

Mrs. IL, a 45-year-old woman, arrives at the emergency department reporting severe pain in the back of her head and neck. She describes it as the “worst headache of her life.” Her medical history includes noncompliance with hypertension treatment and past cigarette use. Initial vital signs are: BP 187/98 mmHg, HR 103 bpm, SpO2 99% on room air, and respiratory rate 22 breaths/minute. Given her symptoms, which of the following would be the ideal blood pressure target for this patient?

A 12-year-old child presents with frequent episodes of moderate headaches, lasting approximately 3 hours each time. The symptoms are typically centralized to the forehead and temples, occur once or twice a month, and are often associated with periods of stress at school. There are no accompanying symptoms such as nausea, vomiting, or photophobia. Which of the following is the most appropriate first-line treatment for this patient’s tension-type headaches?

A 63-year-old female patient with a past medical history of hypertension and hyperlipidemia arrives to the emergency department displaying symptoms of acute weakness on her right side, slurred speech, and sudden vision loss. Upon evaluation using the NIH Stroke Scale, her total score is 23. Based on this NIHSS score, which category of stroke severity best describes her condition?

A 45-year-old male is rushed into the emergency department after a severe motor vehicle accident. On examination, he appears unconscious with significant signs of a head trauma. His vitals include a blood pressure of 190/110 mmHg, a pulse rate of 52 bpm, and an irregular respiration. Based on these symptoms, which of the following would NOT be considered a part of Cushing’s Triad?